Question

The nurse is watching a nursing student work with a patient with increased ICP. When should the nurse intervene? (SATA)

1. keep head in neutral position
2. the student encourages isometric exercises
3. handing them a tissue to blow their nose
4. the student encourages the patient to move up in bed
5. The student pats on the patients back while he coughs up his secretions

Answer 1

The nurse should intervene when the nursing student encourages isometric exercises (2) and the student encourages the patient to move up in bed (4).

The answer is option ⇒2 and 4

Step-by-step explanation:

Isometric exercises involve muscle contractions without joint movement. These exercises can be beneficial for some patients, but they may not be appropriate for all individuals, especially those with certain medical conditions or physical limitations. The nurse should intervene if the student is encouraging isometric exercises without assessing the patient's specific situation and considering any contraindications.

Encouraging a patient to move up in bed may also require the nurse's intervention. While helping patients reposition themselves in bed can be important for comfort and preventing pressure ulcers, it is crucial to consider the patient's physical abilities and any restrictions they may have. Moving a patient without considering their specific needs can lead to injury or discomfort.

In both cases, the nurse should step in to assess the patient's condition, evaluate their capabilities, and provide appropriate guidance or alternative exercises. It is important to prioritize patient safety and well-being by tailoring interventions to their specific needs.

The answer is option ⇒2 and 4